The futility of medicine versus psychology in mental health

The discussion around the utility of medicines and talking therapies for mental illness/psychological distress is pretty damn useless to me; as much use as the nature/nurture debate.

 

The reality is that some people improve through the use of psychotropic medications, some people make progress through talking and behaviour change (which is the product of talking – change takes place outside the therapy room) and some get better without help of any sort.

 

The trick is in determining which person would benefit from which sort of intervention and indeed that they would benefit from professional intervention in the first place!

 

But there are much greater problems that have to be addressed before those questions are addressed. So much of the time the focus is not on the client but professional standing, service requirements and power.

 

I have worked in and around primary care for 20 years after qualifying and during that time I have seen so many professionals lose sight of their role as a health professional  and focus on their careers rather than promoting health or at least “doing no harm”.

 

A good doctor will focus upon the best medication for a particular presentation, the characteristics of the individual and the situation. The trouble with psychiatric medicine is that while there are symptoms there is no source and no signs for most psychiatric diagnoses. This reality makes diagnosis at best a finger in the wind task as it is reliant upon the person’s self report.

 

However, psychology has the same problem with formulation. How does the clinician know when they have gathered enough of the right information to make an accurate formulation, even with the wholehearted co-operation of the individual. Furthermore, how much of the past is relevant to the formulation? Even that knowledge of the past may adversely bias attention toward a particular formulation or diagnosis that is a pet issue for the professional.

 

In mental health, psychiatry, psychology the only expert in their lives is the person experiencing it. Surely our first and foremost question to them should be, what would your life be like if it were working better, if our intervention had been useful; if you were experiencing more of what you wanted? Rather than assuming that they wish to get rid of something which is the traditional approach in both psychiatry and psychology. An approach that has developed from the medical model of treating illness, the removal of infection, pain and physical distress.

 

As psychological beings we all suffer pain and distress, this cannot be entirely eliminated as it is part of the human condition to a greater or lesser extent according to the environment in which we find ourselves. Our own resilience to situations, our perception of what and why it is happening to us determines what impact it has. Trying to diagnose or formulate in those circumstances for an individual response doesn’t make sense unless it draws and builds upon the strengths and qualities of that individual.

 

However, used thoughtfully, medication can be extremely helpful to support a person who is struggling with extremes of mood or sleep or even voices, hallucinations, etc. It is the blanket application and the assumption that it is the only source of relief for distressed people is frankly ridiculous; in the same way the assumption that talking or behaviour modification is the only way to relieve psychological problems.

 

This either/or approach is leading to a polarisation of ways of working with psychiatric/psychological distress that leaves the individual lost in the no man’s land of the battle between the professions.

 

We must return to basics and ask ourselves as professionals what are we working towards? What will good mental health look like for the population? What will we be doing to achieve it? What questions will we be asking of those we are working with and what will they want of us?

 

I have seen far too many professionals hell bent on promoting their own careers, making money and/or fame out of the distress of others. Thinking far too little about the experience of those they are working with; how their interventions impact and how their powerbase biases the control the person has over their own care and how that powerbase may also reflect th person’s previous experience of life with other dominant and possibly abusive figures.

 

Being a powerful and confident professional is not always best; assuming we know what is best for any given individual is arrogant and insightless.

 

It is time for a change of approach to psychological/psychiatric wellness that puts the individual at the centre but that means the professional has to give up their powerful “expert” position and assume, like Socrates, that they really don’t know what the experience of the person they are working with is like. (Except Socrates was being, like all professionals, rather disingenuous as he had an agenda too!)

 

There is a way of working with people that is respectful, based on a future focus (what will be better and a step in the direction that is desired by the person, measurement and testabilty and the strengths, skills and abilities of the person rather than the unpredictable qualities of the professional. It is time to learn about Solution Focus Practice (SFP) as it is for everyone not just an elite “all knowing” powerful group.

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About steveflatt

Director of the PTU in Liverpool. Solution focused practitioner, cognitive therapist, nurse and psychologist.
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One Response to The futility of medicine versus psychology in mental health

  1. keithrlaws says:

    “The reality is that some people improve through the use of psychotropic medications, some people make progress through talking and behaviour change (which is the product of talking – change takes place outside the therapy room) and some get better without help of any sort”

    Hi Steve, an interesting post and I agree up…. to a point … it depends on the ‘disorder’. Some people may well have no need of either medication or talk therapy; and some also ‘get better’ without recourse to either. The key aspect for me though is your claim that some ” improve through the use of psychotropic medications, some people make progress through talking and behaviour change”. We have limited ability to say this within the normal frames of evidence (i.e. RCTs and meta analyses); and in some severe mental disorders, we cannot say this in any form e.g. with schizophrenia, we have no evidence that some people with schizophrenia ‘get better’ with talk therapy – partly because we have never had an RCT of unmedicated patients on talk therapy.

    I agree partly with what you say about diagnosis and psychological formulation – but the lack of ‘signs’ might be considered more an issue to ‘formulation’ because – it seems to me – that some clinical psychologists deny the possibility of biological signs i.e. that the search for markers is irrelevant or pointless. If this is true, then they may be wed to symptomatology i.e dependent upon the self-report of the sufferers experience. And unlike you, I would say that people are most definitely not experts on themselves- of course , they may describe their needs, but in terms of providing unique and reliable insight about their condition…especially when distressed….I would say most of (experimental) psychology argues against that idea
    My views on formulation have been expressed elsewhere http://keithsneuroblog.blogspot.co.uk/2013/05/clinical-psychology-anti-or-ante-science.html and self-knowledge here http://keithsneuroblog.blogspot.co.uk/2013/08/no-thyself-or-another-green-world.html

    I have sympathy for your view that an ‘either-or’ conflict is futile…and I see no reason why an assumed biological problem may not be dealt with psychologically or a psychological problem dealt with via medication. Everyone works within financial and time constraints that make tailored mental health currently seem very unlikely. Nonetheless, the essential problem for clinical psychologists/therapists who deny markers…is that they would seem to have little basis for deciding if a biological or psychological approach would more suitable – I can see how we could decide on approrpiate intervention without a ‘marker’ (which would almost certainly be…biological)

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